Ovarian carcinoma or abdominal tuberculosis?-A diagnostic dilemma: study of fifteen cases

Female genital tuberculosis presented with primary infertility and persistent CA-125 elevation: A case report

Introduction

and importance: Tuberculosis is one of the leading causes of mortality in many developing countries. Female genital tuberculosis, a relatively uncommon form of tuberculosis, is critically challenging to diagnose due to its insidious and non-typical presentations.

Case presentation

Herein, we present with an asymptomatic infertile woman with persistently high CA-125 passed undiagnosed until laparoscopy unveiled the diagnosis of TB.

Clinical discussion

In this study, we highlight the diagnostic complexities in female genital tuberculosis and demonstrate the value of the CA-125 increase in prompting the suspicion of tuberculosis in the appropriate clinical context.

Conclusion

Given the considerably large number of individuals with tuberculosis in China, we strongly recommend routine tuberculosis screening in women seeking infertility care in China.

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Female genital tuberculosis is difficult to diagnose early due to its rarity and insidious symptoms.

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Persistent elevation of CA-125 may indicate the presence of tuberculosis in rare occasions.

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Performing tuberculosis screening routinely for infertile womenin tuberculosis prevailing regions is recommended.

A diagnostic approach for differentiating abdominal tuberculosis from ovarian malignancy: a case series and literature review

Background

Abdominal tuberculosis is an uncommon variant of extrapulmonary tuberculosis. It accounts for 3.5% of extrapulmonary tuberculosis. Diagnosis of abdominal tuberculosis is still a challenge due to its non-specific symptoms. Abdominal tuberculosis and ovarian cancer may show similar symptoms, laboratory and imaging features. The goal of our report is to emphasize for the need of a diagnostic approach based on clinical manifestations, laboratory, imaging findings, and additional tests for considering a diagnosis of abdominal tuberculosis rather than ovarian cancer.

Case presentation

We report 3 cases of abdominal tuberculosis in our Onco-gynaecology Division, Department of Obstetrics and Gynaecology, Sardjito Hospital, Yogyakarta, Indonesia in 2018 which were previously diagnosed as ovarian malignancy and managed surgically. All of our patients experienced abdominal pain and enlargement but only two of them had significant weight loss. The general symptoms were typically found in onco-gynaecology patients, especially in those with ovarian malignancy. Ultrasound examination showed multilocular masses, 2 of them with solid parts and ascites. Cancer antigen 125 (CA-125) levels were found increasing in those three patients. All of them were treated surgically and diagnosis of abdominal tuberculosis was established through the histopathological result of tissue biopsy. Based on our cases and literature, we consider the need of a diagnostic approach to differentiate abdominal tuberculosis from ovarian malignancy, an attempt to avoid unnecessary invasive procedures that put burden risk for the patients.

Conclusion

Minimally invasive tests to establish the diagnosis of abdominal tuberculosis should be optimized to reduce the burden risk of laparotomy. Careful diagnostic steps should be followed to avoid wrong diagnosis.

Peritoneal Tuberculosis: A Forsaken Yet Misleading Diagnosis

In women presenting with an abdominal mass and ascites, the first diagnosis to consider is ovarian cancer. However, clinicians should always consider alternative differentials, namely, peritoneal tuberculosis, especially in the presence of respiratory symptoms and with the increasing prevalence of extrapulmonary tuberculosis. Peritoneal tuberculosis can mimic the clinical presentation of ovarian cancer, and on imaging, it can show similar features of peritoneal carcinomatosis and nodules. Tumor markers can also be elevated in the absence of malignancy. We present the case of a 44-year-old woman with abdominal distension and ascites. Imaging with CT scan, MRI, and PET scan were inconclusive, showing peritoneal nodules. Cytology of ascites was negative. Laparoscopy was done showing Koch bacilli followed by pulmonary sampling showing Mycobacterium tuberculosis. The patient was treated with quadritherapy with resolution of symptoms.

Early stage ovarian carcinoma with symptoms mimicking tuberculous peritonitis in a postmenopausal woman: A case report

RATIONALE

Ovarian cancer has the poorest prognosis of the gynecological cancers. Early diagnosis and treatment are important, but early-stage ovarian carcinoma has nonspecific symptoms. Ultrasonography, computed tomography, magnetic resonance imaging, and serum CA-125 levels can be helpful but may not elucidate cases of diffuse peritoneal diseases mimicking carcinomatosis.

PATIENT CONCERNS

The patient had intermittent abdominal discomfort and dysuria. Abdominal-pelvic computed tomography findings were suspicious for peritoneal tuberculosis (TB) and a small cystic mass in the left ovary. The CA-125 values were normal.

DIAGNOSES

She underwent laparoscopy for pathologic confirmation of tuberculous peritonitis and management of the ovary mass. Bilateral adnexectomy was performed. Histopathological examination of the surgical specimen revealed a serous ovarian carcinoma in her left ovary and salpinx.

INTERVENTIONS

Laparoscopic hysterectomy, pelvic lymphadenectomy, para-aortic nodal dissection, and omentectomy were carried out for staging evaluation.

OUTCOMES

We encountered a rare case of ovary cancer stage IA serous ovarian carcinoma incidentally discovered by laparoscopy in a postmenopausal woman. She received adjuvant chemotherapy without relapse.

LESSONS

Peritoneal TB may mimic peritoneal or ovarian carcinoma, but the reverse case is rare. Hence, gynecologists should be careful in assessment of patients before treatment.

Red Snappers and Red Herrings: Pelvic Tuberculosis Causing Elevated CA 125 and Mimicking Advanced Ovarian Cancer. A Case Report and Literature Review

Female genital tuberculosis (FGTB) is a form of extra-pulmonary tuberculosis that has been primarily described in developing countries, where it is an important cause of infertility, ectopic pregnancy, and miscarriage. FGTB is rare in the United States and because its clinical presentation is non-specific and often insidious, FGTB may be misdiagnosed as a gynecologic malignancy or endometriosis. The tendency of tuberculosis to dramatically increase serum CA 125 levels contributes to the potential for FGTB to be mistaken for ovarian cancer in particular. We describe the case of a young woman who presented with what was initially thought to be advanced ovarian cancer but who had tuberculosis of the peritoneum, uterus, and ovaries discovered at laparotomy. This case emphasizes the importance of considering tuberculosis in the differential of any patient presenting with an abdomino-pelvic mass and an elevated CA 125 level.

CT Differentiation of Female Peritoneal Tuberculosis and Peritoneal Carcinomatosis From Normal-Sized Ovarian Cancer

OBJECTIVE

The purpose of this study was to analyze the computed tomography (CT) features of female peritoneal tuberculosis and peritoneal carcinomatosis from normal-sized ovarian cancer for their differentiation.

MATERIALS AND METHODS

We analyzed the CT features of 18 female peritoneal tuberculosis and 17 peritoneal carcinomatosis with proven normal-sized ovarian carcinomas. Omental change, mesenteric change, parietal peritoneal thickening, lymph node enlargement, ascites, ovarian CT attenuation, and ovarian capsular change were analyzed.

RESULTS

Heterogeneous parenchymal hyperattenuation and capsular change of the ovary were more frequently seen in cases of peritoneal carcinomatosis than in cases of female peritoneal tuberculosis (P = 0.002, P < 0.001, respectively). There were no statistically significant differences in the other CT features.

CONCLUSIONS

The differentiation of female peritoneal tuberculosis and peritoneal carcinomatosis with normal-sized ovarian cancer by CT may be a diagnostic challenge. Ovarian hyperattenuation and any prominent ovarian capsular change may facilitate the differentiation between these groups.

Peri and post-menopausal women with complex adnexal masses, ascites, and raised CA-125: Is it ovarian cancer or tuberculosis?

Pelvic and peritoneal tuberculosis may resemble advanced ovarian cancer due to the presence of ascites, complex adnexal masses, peritoneal deposits and raised CA-125 level, especially in peri- and postmenopausal women. Other common features among women with these two conditions are abdominal pain and distension, weight loss and reduced appetite. As the treatment of pelvic-peritoneal tuberculosis is completely different from that of ovarian cancer, it is important to reach a correct diagnosis. Sometimes women with pelvic-peritoneal tuberculosis may be subjected to a laparotomy for suspected ovarian cancer which is likely to increase their morbidity. In the present article, we report ten women in the peri- and post-menopausal age group where this diagnostic dilemma arose of whom seven were diagnosed only after a laparotomy had been performed for suspected ovarian cancer due to adnexal masses with ascites and raised CA-125 level. Ascitic fluid showing lymphocytic predominance, raised ADA level and absence of malignant cells are pointers to consider the possibility of pelvic- peritoneal tuberculosis, especially in endemic countries like India. In such situations, an effort should be made to obtain a cytological or histopathological diagnosis of either condition by ultrasound guided needle biopsy or laparoscopically obtained biopsy rather that proceeding with laparotomy for suspected ovarian cancer.

Pelvic tuberculous granuloma successfully treated with laparoscopy to preserve fertility: a case report and review of the published work

Tuberculous granuloma must be considered in the differential diagnosis of pelvic masses in women of reproductive age because the major sequela of pelvic tuberculosis is infertility; however, currently there is very little information about its fertility-preserving treatment. We report the case of a woman with a history of tuberculous peritonitis who referred to our hospital for evaluation of an adnexal mass and primary infertility. The patient underwent excision of pelvic tuberculous granuloma with fertility-preserving laparoscopic surgery. We resected as much of the tuberculous granuloma as possible using the laparoscopic technique without causing damage to the uterus or ovaries. In particular, we report for the first time in the published work the laparoscopic removal of tuberculous granuloma without causing damage to the uterus or ovaries. Our experience from this case suggests that laparoscopic diagnosis and treatment of tuberculous granuloma is a feasible procedure in a patient who wants to conceive.

Challenges and perspectives in the diagnosis of extrapulmonary tuberculosis

Extrapulmonary tuberculosis (EPTB) accounts for a significant proportion of tuberculosis cases worldwide. Nevertheless, the diagnosis is often delayed or even missed due to insidious clinical presentation and poor performance of diagnostic tests. Culture, the classical gold standard for tuberculosis, suffers from increased technical and logistical constraints in EPTB cases. In this review the authors outline current diagnostic options for the main forms of EPTB. The authors also discuss the opportunities and challenges linked in particular to microbiological diagnostics and to the attempts to find a new gold standard test for EPTB. Finally, new biomarkers and tests currently under evaluation are hopefully on the way to introduce significant improvements in EPTB diagnosis, for which clinical suspicion will nevertheless be essential.